CONTACTS 
0201 - Medical Offices Lisa Bailey                                                                                                                                        O-00000850 0101
020101 - Ms. Lisa Bailey, MD                                                                                                                                              O-00000850 0101
020103 - Executive Office                                                                                                                                                 O-00000850 0101

SUBJECTS
Palliation Mastectomy Surgery May Reduce Palliation Increase Risk IB

0903 -
0903 -    ..
0904 - Summary/Objective
0905 -
090501 - Follow up ref SDS 44 0000. ref SDS 36 0000.
090502 -
090503 -
090504 -
090505 -
090507 -  ..
0906 -
0907 -
0908 - Progress
0909 -
090901 - Disease-free Status NED Purpose Mastectomy Reduce Risk Relapse
090902 - Purpose Wide Area Mastectomy Reduce Risk Relapse Not Palliation
090903 - Mastectomy Purpose Reduce Risk Relapse with Wide Area Not Palliation
090904 - Palliation for Disease-free Patient Cure Purpose Very Wide Mastectomy
090905 -
090906 - Doctor Bailey called this afternoon and discussed recent developments
090907 - presented in a letter yesterday on 051010, ref SDS 44 X93F, and, also,
090908 - discussed with Doctor Grissom yesterday. ref SDS 44 GW4I
090909 -
090910 - Submitted ref DIT 1 0001 to Doctor Bailey confirming telecon....
090912 -         ..
090913 -    3.  Thanks for your call this afternoon, and for taking time
090914 -        between surgeries to comment on Millie's progress, responding
090915 -        to the letter to you yesterday (see below). ref DIT 1 0001
090917 -         ..
090918 -    4.  You indicated today that there is no evident basis for
090919 -        "palliative" mastectomy surgery in Millie's case, as called out
090920 -        by the primary care physician... in a meeting on 051007.  The
090921 -        record on this meeting has not yet been posted; however,
090922 -        yesterday Millie got a copy of the Doctor's notes in connection
090923 -        with filing a disability claim. ref DIT 1 G66W [Primary care
090924 -        physician] says in part...
090926 -             ..
090927 -            "She was seen by the plastic surgery and the decision was
090928 -            that reconstruction would add no value to our current
090929 -            palliative strategy." ref SDS 45 SM6M
090931 -         ..
090932 -    5.  Setting aside inaccuracy of the doctor's expression, the above
090933 -        sentence is the total record from the doctor on "palliative
090934 -        surgery."  During a meeting on 050913, [primary care physician]
090935 -        gave the name of another doctor at Kaiser in whom he seems to
090936 -        place great reliance for treating IBC.  He may have had
090937 -        conversations which are not entered in the record. ref DIT 1
090938 -        G68P
090940 -         ..
090941 -    6.  "Palliative strategy" for mastectomy surgery was mentioned for
090942 -        the first and only time  during the meeting last Friday, on
090943 -        051007.  Previously, on 050913 the doctor was adamant that
090944 -        mastectomy was required to save the patient's life, which seems
090945 -        to aim higher than palliation.  In any event, as you note, the
090946 -        doctor has a strong commitment to Millie having surgery.
090947 -        ref DIT 1 J687
090949 -         ..
090950 -    7.  You indicated in our call that treatment for primary IBC is
090951 -        chemo to reduce inflammation, then surgery to remove the tumor
090952 -        that causes IBC, and then more chemo and finally radiation.
090953 -        You further noted that in Millie's case of secondary IBC, where
090954 -        the tumor has been previously removed, and where the breast has
090955 -        been radiated, then there is no purpose for a standard
090956 -        mastectomy.  You indicated that if a mastectomy were to be
090957 -        performed, then the only reasonable objective is to try
090958 -        removing previously infected skin that may retain remnants of
090959 -        disease in the lymphatics which is not evident by observing the
090960 -        skin, and so does not show up from testing.  The primary care
090961 -        physician cited this concern on 051007 about microscopic cancer
090962 -        cells that could recur in connection with a "palliative
090963 -        strategy." ref SDS 43 I482  You noted today, that to remove
090964 -        only a portion of previously infected skin, as occurs with a
090965 -        standard mastectomy, has no value in reducing risk of
090966 -        recurrence. ref DIT 1 G69U
090967 -
090968 -
090969 -
0910 -

SUBJECTS
Palliation Fails Mastectomy Surgery Removes Blood Vessels Capillarie

2603 -
260401 -     ..
260402 -    Mastectomy IBC Relapse Chemotherapy Reduced Effectiveness
260403 -    Brest Removal Mastectomy Surgery Risks Recovery IBC Relapse
260404 -    Blood Vessels Removed Mastectomy Reduces Chemotherapy Effectiveness
260405 -
260406 -
260407 -    8.  You further advised that removing breast mass with surgery
260408 -        would likely frustrate aims for palliation presented on 051007,
260409 -        ref SDS 43 6A4N, by actually accelerating disease, if IBC
260410 -        relapse occurs, because there will be fewer blood vessels,
260411 -        veins, and capillaries to service infected skin with systemic
260412 -        treatment, ref DIT 1 XS4L, and perhaps with the body's immune
260413 -        system (although we did not discuss the immune system),
260414 -        reflecting Doctor Smith's analysis at Kaiser on 050928.
260415 -        ref SDS 41 248I
260417 -  ..
260418 - This scenario of mastectomy removing blood vessels and preventing
260419 - delivery of treatment to infected tissue may compound concerns about
260420 - pockets of resistance to chemotherapy presented by the primary care
260421 - physician on 050311. ref SDS 11 PA4N  This would increase resistance
260422 - to treatment when disease progresses through cancer mutation, cited by
260423 - the primary care physician on 030606. ref SDS 2 N27L  Doctor Benz
260424 - made a similar point about disease progerssing that requires changing
260425 - treatment in a 2nd opinion received on 041117.
260426 -
260427 -            [On 051012 opportunities and risks of mastectomy surgery
260428 -            following Kaiser's requirements for Time Out to perform due
260429 -            diligence, ref SDS 46 IH4P; risk of slow recovery from IBC
260430 -            relapse due to loss of blood vessels for delivering
260431 -            chemotherapy treatment cited. ref SDS 46 IC37
260433 -             ..
260434 -            [On 051018 denial overlooks due diligence "Time Out"
260435 -            analysis, ref SDS 47 145G, of future requirements for blood
260436 -            vessels to deliver treatment in the event of relapse after
260437 -            surgery. ref SDS 47 687Y
260439 -             ..
260440 -            [On 051027 surgeon reports having stretched skin and tissue
260441 -            sufficiently for standard closure of a wider than normal
260442 -            mastectomy, and this maintains sufficient blood vessel and
260443 -            related body mass for delivering nutrients and treatment,
260444 -            if necessary, for normal healing of the surgical wound, and
260445 -            in the event of IBC relapse. ref SDS 48 QY8K
260447 -             ..
260448 -            [On 060808 IBC relapse disease progresses with treatment
260449 -            that previously was effective; scenario #2 review meeting
260450 -            consider changing chemotherapy agent. ref SDS 49 HT5K
260452 -             ..
260453 -            [On 060821 2nd opinion Doctor Benz ask about expectations
260454 -            for fast recovery tempered by mastectomy surgery that
260455 -            reduces effectiveness of chemotherapy treatment.
260456 -            ref SDS 50 NN3H
260458 -             ..
260459 -            [On 060922 analysis of slow recovery with same chemotherapy
260460 -            treatment following IBC relapse, ref SDS 51 9E6L, cites
260461 -            Doctor Bailey's anlaysis on the impact of diminished
260462 -            capacity for blood vessels. ref SDS 51 ML3I
260464 -             ..
260465 -            [On 061110 doctor reports IBC rash on left breast area is
260466 -            "stable," ref SDS 53 ZL5W, indicating recovery is very
260467 -            slow, because on 051021 blood vessels were removed from the
260468 -            treatment area by mastectomy surgery, per analysis of
260469 -            expectations on 060929. ref SDS 52 EH3F
260471 -         ..
260472 -    9.  Finally, you commented that following surgery, or if Millie
260473 -        elects not to have surgery, if the skin biopsies tomorrow are
260474 -        positive, and further if she has surgery and the pathology
260475 -        finds no remnants of cancer, then this would present a
260476 -        favorable test result that could support ending chemotherapy
260477 -        treatments, scaling treatments back, or changing to a less
260478 -        debilitating regimen.  I know Millie will be pleased to hear
260479 -        this. ref DIT 1 G66P
260481 -         ..
260482 -   10.  Maybe this is a basis for a mastectomy simply to test the
260483 -        underlying tissue more rigorously, although previously on
260484 -        040419 a punch biopsy into the breast identified IBC, and so
260485 -        possibly this less invasive procedure might be more
260486 -        appropriate.  In any case, the train seems to be moving toward
260487 -        mastectomy.  I will suggest that Mil ask Kaiser to complete its
260488 -        standard "Time Out" pre-surgery work up to explain the purpose
260489 -        of the procedure, define "success", and list prior cases of
260490 -        secondary IBC that have been treated successfully with the
260491 -        proposed surgery. ref DIT 1 G66Y
260492 -
260493 -             [On 051015 Millie decided not to ask Kaiser to perform
260494 -             required "Time Out" procedures for risk management to
260495 -             verify surgery offers the best course of treatment for
260496 -             Millie.
260498 -         ..
260499 -   11.  No need to respond, unless I am way off on representing your
260500 -        views.  By copy letting Millie know of our discussion.
260501 -        ref DIT 1 PQPX
260503 -         ..
260504 -   12.  Thanks again for taking time between surgeries for this
260505 -        consultation. ref DIT 1 G74T
260506 -
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2606 -